Dental Benefits

Annual Deductible*
(Individual/Family)

$50/$150

$50/$150

Preventive Services

100% (No Deductible)

80% (No Deductible)

Basic Services

80%

70%

Major Services

50%

40%

Annual Benefit Max

$1,250

$1,250

Office Visit Copay

N/A

N/A

Orthodontic Services**

50%

50%

Orthodontic Deductible

None

None

Orthodontic Max

$1,250

$1,250

Preventive

Oral Examinations (a)

100%

80%

Cleanings (a) Adult/Child

100%

80%

Fluoride (a)

100%

80%

Sealants (permanent molars only) (a)

100%

80%

Bitewing Images (a)

100%

80%

Full Mouth Series Images (a)

100%

80%

Basic

Composite Fillings

80%

70%

Recementation (inlays, crowns, and bridges) (a)

80%

70%

Periodontics

80%

70%

Endodontics (a)

80%

70%

Tooth Extraction (a)

80%

70%

General anesthesia

80%

70%

Major

Bridges

50%

40%

Crowns

50%

40%

Full & Partial Dentures

50%

40%

*The deductible applies to: Basic & Major services only
**Orthodontia is covered only for children (appliance must be placed prior to age 19).

Employee Only

$12.62

Employee + Spouse

$24.55

Employee + Children

$34.22

Family

$46.19

Employee

$18.93

Employee + Spouse

$36.82

Employee + Child(ren)

$51.33

Family

$69.28